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Interact CardioVasc Thorac Surg 2009;8:62-65. doi:10.1510/icvts.2008.184747
© 2009 European Association of Cardio-Thoracic Surgery
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Institutional report - Thoracic general

Sixty tracheal resections – single center experience{star}

Ioan Cordos, Ciprian Bolca*, Cristian Paleru, Radu Posea and Radu Stoica

1st Clinical Department of Thoracic Surgery, National Institute of Pneumology Marius Nasta, 90, Viilor Street, Sector 5, Bucharest, Romania

Received 28 May 2008; received in revised form 9 September 2008; accepted 17 September 2008

{star} Presented at the 16th European Conference on General Thoracic Surgery, Bologna, Italy, June 8–11, 2008.

*Corresponding author. Tel.: +4 0722 242019; fax: +4 021 3373801.

E-mail address: bolcaciprian{at}gmail.com (C. Bolca).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 Conference discussion
 References
 
This study evaluates the clinical outcome following surgery of our patients for the last seven years. Between 2001 and 2008 we performed tracheal resections in 60 patients. There were 46 cases of postintubation stenosis and 14 tumors. The range of resected rings was 1–8. The maximal resection length performed in our series (4 cm) was achieved using only basic releasing maneuvers such as anterior dissection of the trachea and cervical flexion. Emergency tracheal resection with no complications was performed in 12 patients who presented with severe dyspnea due to very tight stenosis. One patient died during the surgical intervention from a stroke. There were two postoperative deaths, both in patients with tracheo-esophageal fistula. As major complications we mention one patient with restenosis who underwent revision surgery. Among the patients with malignant tumors we had one local epidermoid carcinoma recurrence 18 months after surgery and the two patients with thyroid cancer who died six and nine months later. Basic releasing maneuvers allow a good length of the trachea to be resected with no complications. We consider that emergency tracheal resection can be performed with success. Squamous cell carcinoma was the most frequent histological type in our series.

Key Words: Tracheal resection; Tracheal stenosis; Tracheal tumor; Tracheoesophageal fistula


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 Conference discussion
 References
 
A wide variety of pathologic conditions involves the trachea. The most effective treatment for these abnormalities is the tracheal resection. The surgical indication addresses to the tracheal stenosis which can be acquired or neoplastic.

Acquired lesions include stenosis due to different tracheal pathologic conditions (postintubation, inflammatory, idiopathic). Any lesion that produces enough symptoms to limit the activity of a patient should be considered for surgery. Traumatic injury to the airway may also require resection and reconstruction. Benign tumors of the trachea can almost always be resected with primary end-to-end anastomosis. Malignant lesions, either primary tracheal tumors or tracheal involvement by thyroid tumors, may also be treated with resection and reconstruction.

Non-operative treatments, including repeated dilation, laser treatment, and prolonged or permanent stenting with T tubes and other stents, are indicated in carefully selected patients and are mainly used to stabilize the stenosis before surgical intervention.

The purpose of this study is to evaluate the outcome following the surgical management of our patients. The study is a review of a retrospectively gathered database.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 5. Conclusions
 Conference discussion
 References
 
Between 2001 and 2008, 60 consecutive patients underwent tracheal resection and reconstruction for different pathology. There were 34 males and 26 females with a median age of 38 years (range 11–82 years).

We divided the patients into two groups: postintubation (acquired) lesions (group A – 46 patients – 77%) and tumoral lesions (group B – 14 patients – 23%). The complete situation is presented in Table 1.


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  		Table 1 Underlying pathology of tracheal stenosis

 
All patients were symptomatic. They all presented with coughing, dyspnea, stridor and we encountered hemoptysis in 13 cases from group B. All six patients with tracheo- esophageal fistula had typical swallow-cough sign. Preoperative assessment included endoscopic examination, chest X-ray and CT-scan to evaluate the extent of the airway involvement and distant metastases in case of tumoral lesions. Most of the lesions (n=53) were situated in the upper third of the trachea with 39 cases of laryngeal involvement. There were three cases of stenosis in the middle third of the trachea and four patients with lower third lesions (Table 2).


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  		Table 2 Lesion locations

 
Prior to the surgery a number of patients received endoscopic treatment as follows: all cases with postintubation stenosis (40) were repeatedly dilated (between 2 and 6 sessions) and three patients from group B, one hemangioma and the two secondary tracheal tumors underwent laser resections.

We used the techniques described by Pearson et al. [1] and Grillo et al. [2]. Simple cervical approach by a collar incision was used in 53 cases (with the tracheostomy stoma included when present), cervical incision with partial sternal split in three and posterolateral thoracotomy in four cases. We performed 21 tracheal resections and 39 cricotracheal resections. The length of resection ranged between 1.5 and 4 cm. The range of resected rings was 1 to 8.

The patients were intubated initially with a small caliber endotracheal tube until the trachea was exposed and circumferentially dissected, sparing the inferior laryngeal nerves. The tracheal dissection was as long as the extent of the lesion. Only the anterior and lateral portions of the cricoid cartilage were removed when we encountered laryngeal involvement. During resection and anastomosis the patients were kept ventilated by means of a distal intubation tube. In cases where we had lesions of the middle and lower third of the trachea we used high frequency jet ventilation. In patients with tracheoesophageal fistula, the closure of the esophageal wall was performed with 4.0 Polydioxanone interrupted sutures and we used a local muscular flap to isolate it from the tracheal anastomosis. For the posterior wall of the trachea we always used a continuous 4.0 Polydioxanone suture between the cartilaginous-membranous angles, and for the anterior wall we used a continuous suture in case of tracheo-tracheal end-to-end anastomosis and interrupted sutures in case of crico-tracheal anastomosis. In the case of the two secondary tracheal tumors, due to direct invasion of a thyroid cancer, we performed ‘en-bloc’ resection of the specimen. All operative specimens in group B were checked for the absence of tumor tissue in the resection margin by frozen section. It was achieved R0 in all patients except thyroid tumors where it was R1 in both patients. We performed complete mediastinal lymphadenectomy in two cases of squamous cell carcinoma of the lower third of the trachea approached by posterolateral thoracotomy. The patients with malignancies were referred to oncology for adjuvant treatment.

Twelve patients presented with severe dyspnea due to very tight stenosis. We performed rigid bronchoscopy for emergency desobstruction and evaluation on the operating table, followed immediately (10 patients from group A) or in the next few hours (two patients from group B) by tracheal resection. There were no complications in this subgroup of patients and this is why we consider that emergency tracheal resection can be safely performed.

There were described a number of releasing maneuvers to have a tension-free anastomosis, but in our series we used pretracheal mobilization and cervical flexion in all patients, these being enough for a 4 cm (eight cartilages) resection. Hilum dissection was performed in one case and pericardial incisions over the inferior margin of inferior pulmonary vein in three patients, when we approached the trachea by posterolateral thoracotomy. No laryngeal releasing maneuver was performed.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 5. Conclusions
 Conference discussion
 References
 
All patients were extubated in the operating room except for one (1.6%) patient from group A who died during the surgical intervention from a stroke. There is a distinct possibility that this happened due to manipulation of carotid arteries during dissection. There were two (3.4%) postoperative deaths, both in patients with tracheo-esophageal fistula (1st two operated). One of them died on postoperative day 4 by an innominate artery fistula with a significant loss of blood and the other one by mediastinitis on postoperative day 21. In the first case an extensive dissection of the entire region was performed, including the arterial brachiocephalic trunk and the tracheal anastomosis was not protected by covering tissue, and in the second case the patient developed an anastomotic leakage with mediastinitis and severe sepsis.

Short-term results were excellent (no complications) in 50 patients (83%), and good (minor complications) in 7 (12%). There were five wound infections (8.3%) and two cervical hematomas (3.4%) as minor complications.

Postoperative hospitalization ranged between 4 and 10 days with a median of 7 days.

Follow-up ranged between three-months and seven years. Three months after operation we encountered one patient (1.66%) with recurrent stenosis who underwent revision surgery with a good outcome. Among the patients with malignant tumors we had one local squamous cell carcinoma recurrence 18 months after surgery and the two patients with thyroid cancer died six and nine months later due to metastatic disease (Table 3). In these two cases the surgery was performed with palliative purposes only. The other four patients with malignancies (one with adenoid cystic carcinoma, one with atypical carcinoid and two with squamous cell carcinoma) were disease free at 24 months after surgery. We lost from follow-up two cases of squamous cell carcinoma. The patients with benign tumors had an excellent evolution, and they are all alive and well. There was only one anastomotic leakage in our series, the patient that died by mediastinitis on postoperative day 21.


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  		Table 3 Results

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
5. Conclusions
 Conference discussion
 References
 
The management of tracheal stenosis of different etiology remains a challenge, requiring a multidisciplinary team. The various nonsurgical methods of treatment are usually helpful to stabilize the lesion, but can even extend the damage unless complemented by surgical cure [3]. As an observation, the fibrosis around the lesions was more extensive in patients that received laser treatment prior to surgery.

The length that can be safely cut during tracheal resection is still controversial. It is very important to avoid tension in the anastomosis, this being the main cause of anastomotic leakage that can be fatal in most of the cases. We were able to resect with no complications a total of eight tracheal cartilages (4 cm in length) using only pretracheal mobilization and cervical flexion. A number of studies suggest that the tension reduction of the anastomosis should take precedence over surgical margins when performing surgical treatment of primary tracheal cancer, with no long-term survival differences [4, 5].

The series published in the literature showed good outcome with low mortality and morbidity (Table 4). A higher rate of complications is shown in studies regarding the tumoral stenosis only [5, 6].


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  		Table 4 Literature data

 
The main cause of stenosis in our series was postintubation tracheal injury. Primary tracheal tumors are rare and thereafter only a small number of cases are reported, but we agree that surgery gives the best local control. Our histological findings are different from those presented in the literature [7, 8]. A complete situation can be seen in Table 2. The most frequent histological type in our series was by far squamous cell carcinoma (five cases – 42% of primary tracheal tumors) while Schneider et al. [6] show the adenoid cystic carcinoma as being the most frequent tumor they encountered in a comparable number of cases (7 patients from a total of 14). We have resected only one case of adenoid cystic carcinoma. Hazama et al. [5] operated on a total of 16 patients with primary tracheal tumors, nine with squamous cell carcinoma and seven with adenoid cystic carcinoma.


   5. Conclusions
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
Conference discussion
 References
 
Basic releasing maneuvers such as anterior dissection of the trachea and cervical flexion allows a good length of the trachea to be resected with no complications. We consider that emergency tracheal resection (the first 24 h) can be performed with success. Squamous cell carcinoma was by far the most frequent histological type in our series compared with other studies. Results obtained in cases of secondary tracheal tumors are not encouraging.


   Conference discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 Conference discussion
References
 
Dr. R. Santosham (Chennai, India): Two short questions. One is in patients who were laserized, did you find more technical difficulty, because our observation has been once laser is used, the tracheal wall gets very much thickened and the area of resection becomes much longer. The other thing is in your tracheoesophageal fistula cases that you showed, our main anxiety is leak from the esophagus. Did you use any other covering material while closing the esophagus, and what is your incidence of immediate vocal cord dysfunction after your cases?

Dr. Cordos: For the first question, we perform resection in the first few hours after laser therapy, and there is no problem to do the surgery because the fibrosis is not initiated in a few hours, probably after two or three days. As you saw in the picture, we perform immediately after this, because the bronchoscopist shows us the remaining tissue, and probably it cannot heal without surgery.

And the second one, tracheoesophageal fistula, we have only six cases. We put the sub-thyroid muscle between the trachea and the esophagus, and we have no problem with the laryngeal nerves in our series.

Dr. Patterson: And there was a question about vocal cord dysfunction also.

Dr. Cordos: No vocal cord dysfunction in our series.

Dr. H-B. Ris (Lausanne, Switzerland): I have a question regarding the intrathoracic tracheal portion above the carina. I found this is a very difficult region to do circumferential resection of a certain length because you have virtually no possibility to mobilize this tracheal segment. What is your opinion? Do you have tricks? What is the length of resection you can do in the intrathoracic portion of the trachea above the carina?

And the second question, you had four cases of squamous cell carcinoma. Where were they localized and were they all resected and healthy tissues?

Dr. Cordos: For the first one, to perform a lower tracheal resection, as you know from the literature, we use the dissection of the pulmonary hilum, and this permits to release the anastomosis. Our length of segment of trachea resected was 2.5 cm in this area.

Dr. Ris: I specifically asked for resections of the supracarinal part of the intrathoracic trachea where we found that release maneuvers do not allow for a satisfactory mobilization of the tracheal segments in order to perform a tension-free anastomosis.

Dr. Cordos: No, no, above the carina. The lower third of the trachea.

Dr. Ris: There we found typically that the release maneuvers are not very helpful. You found the high release maneuver very helpful?

Dr. Cordos: Fortunately, this patient was the oldest, 82 years, with most part of the trachea situated intrathoracic and the maneuvers that we performed – hilum dissection and neck flexion were enough for a 2.5 cm resection; he is now alive after two years. This is the evidence.

And the second question was about?

Dr. Ris: About squamous cell carcinoma, whether or not they were resected in healthy tissue.

Dr. Cordos: The margin of the segment resected was sent to the pathologist, and he told us that the margin was free of neoplasia.

Dr. M. Bijelovic (Novi Sad, Serbia): My question is, your longest resected segment of trachea was 4 cm. For longer stenosis, do you consider longer stenosis inoperable or you simply hadn't longer stenosis?

Dr. Cordos: The longest stenosis operated by us one month ago was nine rings (4.5 cm), and we also performed this using only neck flexion, and anterior dissection in the pretracheal avascular space. I consider that even longer portions can be resected.

Dr. I. Motus (Ekaterinburg, Russia): I have a question for you. What kind of artificial lung ventilation do you prefer performing the anastomosis?

Dr. Cordos: The question was about some tricks in anesthesiology in these cases. We have a very good relation with the anesthesiologist and he stays all the time in the operation room. And we use the crossfield intubation of the distal part of the trachea, until we perform the posterior suture, almost in all cases with a running suture, and then he has a tube in the larynx and it is pulled down in the distal trachea, and we perform the anterior part of the anastomosis. In some cases when we perform the lower third resection of the trachea, we use high-frequency jet ventilation. I consider it very easy to perform the running suture around this very thin tube.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 5. Conclusions
 Conference discussion
 References
 

  1. Pearson FG, Cooper JD, Nelems JM, Van Nostrand AW. Primary tracheal anastomosis after resection of the cricoid cartilage with preservation of recurrent laryngeal nerves. J Thorac Cardiovasc Surg 1975;70:806–816.[Abstract]
  2. Grillo HC, Mathisen DJ, Ashiku SK, Wright CD, Wain JC. Successful treatment of idiopathic laryngotracheal stenosis by resection and primary anastomosis. Ann Otol Rhinol Laryngol 2003;112:798–800.[Medline]
  3. Ciccone AM, De Giacomo T, Venuta F, Ibrahim M, Diso D, Coloni GF, Rendina EA. Operative and non-operative treatment of benign subglottic laryngotracheal stenosis. Eur J Cardiothorac Surg 2004;26:818–822.[Abstract/Free Full Text]
  4. Pearson FG, Thompson DW, Weisberg D, Simpson WKJ, Kergin FG. Adenoid cystic carcinoma of the trachea. Ann Thorac Surg 1974;18:16–29.[Medline]
  5. Hazama K, Miyoshi S, Akashi A, Yasumitsu T, Maeda H, Nakamura K, Tada H, Matsuda H. Clinicopathological investigation of 20 cases of primary tracheal cancer. Eur J Cardiothorac Surg 2003;23:1–5.[Abstract/Free Full Text]
  6. Schneider P, Schirren J, Muley T, Vogt-Moykopf I. Primary tracheal tumors: experience with 14 resected patients. Eur J Cardiothorac Surg 2001;20:12–18.[Abstract/Free Full Text]
  7. Gaissert HA, Grillo HC, Shadmehr MB, Wright CD, Gokhale M, Wain JC, Mathisen DJ. Uncommon primary tracheal tumors. Ann Thorac Surg 2006;82:268–272.[Abstract/Free Full Text]
  8. Stamatis G, Freitag L, Greschuchna D. Limited and radical resection for tracheal and bronchopulmonary carcinoid tumour. Report on 227 cases. Eur J Cardiothorac Surg 1990;4:527–532.[Abstract]
  9. Grillo HC, Donahue DM, Mathisen DJ, Wain JC, Wright CD. Postintubation tracheal stenosis. Treatment and results. J Thorac Cardiovasc Surg 1995;109:486–492.[Abstract/Free Full Text]
  10. Couraud L, Jougon J, Velly JF, Klein C. Iatrogenic stenoses of the respiratory tract. Evolution of therapeutic indications. Based on 217 surgical cases. Ann Chir 1994;48:277–283.[Medline]
  11. Tarrazona VH. Limites de la cirugia de reseccion traqueal. Rev Patol Respir 2001;4:1–2.
  12. Rea F, Callegaro D, Loy M, Zuin A, Narne S, Gobbi T, Grapeggia M, Sartori F. Benign tracheal and laryngotracheal stenosis: surgical treatment and results. Eur J Cardiothorac Surg 2002;22:352–356.[Abstract/Free Full Text]
  13. Amorós JM, Ramos R, Villalonga R, Morera R, Ferrer G, Díaz P. Tracheal and cricotracheal resection for laryngotracheal stenosis: experience in 54 consecutive cases. Eur J Cardiothorac Surg 2006;29:35–39.[Abstract/Free Full Text]
  14. Marulli G, Rizzardi G, Bortolotti L, Loy M, Breda C, Hamad AM, Sartori F, Rea F. Single-staged laryngotracheal resection and reconstruction for benign strictures in adults. Interact Cardiovasc Thorac Surg 2008;7:227–230.[Abstract/Free Full Text]
  15. D'Andrilli A, Ciccone AM, Venuta F, Ibrahim M, Andretti C, Massullo D, Formisano R, Rendina EA. Long-term results of laryngotracheal resection for benign stenosis. Eur J Cardiothorac Surg 2008;33:440–443.[Abstract/Free Full Text]

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